Provider Demographics
NPI:1629944467
Name:CRUME, MADDIE
Entity type:Individual
Prefix:
First Name:MADDIE
Middle Name:
Last Name:CRUME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 HAW CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 HAW CREEK BLVD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9681
Practice Address - Country:US
Practice Address - Phone:208-580-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health